It depends, but most folks might never have it done!
Vaccines work very well, so you would typically not need to routinely check and confirm that you are immune after being vaccinated. And, this is also important, the vaccine titer tests don’t always work that well, titer testing isn’t available for all vaccines (you can’t do titer testing for Hib and pertussis), and the testing can be expensive.
So we usually just do the testing (a quantitative titer) for folks that are in high risk situations, including:
pregnancy – rubella titer only (HBsAg is also done, but that’s not a vaccine titer test, but rather to see if you are chronically infected with hepatitis B)
healthcare workers – anti-HBs (antibody to the hepatitis B surface antigen to confirm immunity after being vaccinated)
students in nursing school and medical school, etc. – anti-HBs
children and adults exposed in an outbreak – measles, chicken pox, mumps, etc., but only if we are unsure if they were previously vaccinated and protected
after a needlestick injury, etc. – to confirm immunity to hepatitis B
internationally adopted children – to confirm that they are immune if we unsure about all of the vaccines the child got in other countries
children and adults with lost vaccine records – to confirm that they are immune, since we are unsure about all of the vaccines they got
evaluation of children and adults with immune system problems – to help identify what immune system problems they might have – typically involves checking pneumococcal titers, giving Prevnar, and then checking pneumococcal titers again
people at continuous or frequent risk for rabies – rabies titer testing every 6 months to 2 years
patients with inflammatory bowel disease, before starting immunosuppressive therapy – hepatitis A and hepatitis B titers, as they might be at increased risk for hepatitis
While checking titers is easy, it is sometimes harder to know what to do with the results you get.
It is especially important to know that:
most people don’t need to have their titers checked routinely if they are not in one of the high-risk groups noted above
it isn’t practical to get titers tested as a method of potentially skipping one or more doses of your child’s vaccines, after all, if the titer is negative, then you are still going to have to get vaccinated
a healthcare provider with a negative measles titer after two doses of the MMR vaccine does not need another dose of vaccine
a healthcare provider who has anti-HBs <10 mIU/mL (negative titer) after three doses of the hepatitis B vaccine should get another dose of vaccine and repeat testing in 1 to 2 months – if still <10 mIU/mL, they should then get two more doses of hepatitis B vaccine (for a total of 6 doses) and repeat testing. If still negative, these documented nonresponders will need HBIG as post-exposure prophylaxis for any future hepatitis B exposures, but no further doses of hepatitis B vaccine.
vaccinated women of childbearing age who have received one or two doses of rubella-containing vaccine and have rubella serum IgG levels that is not clearly positive should be administered one additional dose of MMR vaccine, with a maximum of three doses, and should not be tested again
in addition to not being able to test titers for pertussis and Hib immunity, it is becoming difficult to test poliovirus type 2 titers, as the test uses a live virus that isn’t routinely available anymore (type 2 polio has been eradicated)
While some folks still believe that the flu is a mild infection, most people understand that the flu is a very dangerous disease.
A dangerous disease that kills hundreds of children and tens of thousands of adults each year in the United States.
Who Dies from the Flu?
In addition to thinking that the flu isn’t dangerous, some folks misunderstand just who is at risk for dying from the flu.
While it is certainly true that some people at higher risk than others, including those who are very young, very old, and those with chronic medical problems, it is very important to understand that just about anyone can die when they get the flu.
Just consider the 2017-18 flu season, in which 185 children died.
In addition to the fact that half of the kids who died were otherwise healthy, without an underlying high risk medical condition, it is important to realize that up to 80% were unvaccinated.
While I’m sure that many parents would love to get their kids vaccinated and protected against RSV, unfortunately, we don’t yet have an actual RSV vaccine.
We do have Synagis (palivaizumab) though, a monthly injection that can be given to high risk children during RSV season to help prevent them from getting RSV.
Do My Kids Need Synagis?
Synagis is not a vaccine and doesn’t stimulate your body to make antibodies, but is instead an injection of RSV antibodies made by recombinant DNA technology. That’s why you need to get an injection each month. The antibodies don’t last much longer.
So why doesn’t everyone get Synagis if RSV can be such a deadly disease?
For one thing, there is the high cost of Synagis injections, but there is also the fact that Synagis is only approved to be given to kids who are at high risk for severe RSV infections.
“Palivizumab prophylaxis has limited effect on RSV hospitalizations on a population basis, no measurable effect on mortality, and a minimal effect on subsequent wheezing.”
AAP on Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection
And Synagis doesn’t have as a great an effect on preventing RSV infections as we would like. That’s why we need a real RSV vaccine instead.
So because it likely doesn’t provide that much help to kids who aren’t at very high risk for severe disease, the latest guidelines recommend that Synagis be given to:
pre-term infants born before 29 weeks, 0 days’ gestation and who will be younger than 12 months at the start of the RSV season
preterm infants with CLD of prematurity, defined as birth at <32 weeks, 0 days’ gestation and a requirement for >21% oxygen for at least 28 days after birth.
certain infants with hemodynamically significant heart disease during their first year of life and might include infants with cyanotic heart defects, infants with acyanotic heart disease who are receiving medication to control congestive heart failure and will require cardiac surgical procedures and infants with moderate to severe pulmonary hypertension, infants with heart lesions that were corrected by surgery, but who continue to require medications for congestive heart failure, and children under age two years who have had a cardiac transplant.
certain children in their second year of life if they required at least 28 days of supplemental oxygen after birth and who continue to require medical intervention (supplemental oxygen, chronic corticosteroid, or diuretic therapy)
certain infants in their first year of life with pulmonary abnormality or neuromuscular disease that impairs the ability to clear secretions from the upper airways
certain children in their second year of life if they will be profoundly immunocompromised during RSV season
Those who qualify get up to five monthly doses, beginning in November, to help make sure they are covered through the peak of RSV season – December to May.
Whether or not your high risk child gets Synagis, you can help to reduce their risk of getting RSV by making sure they are not exposed to tobacco smoke, keep them away from crowds of people, wash hands often, and if possible, keep them out of day care.
What do you do if your high risk child was denied Synagis by your insurance plan? If your infant has a qualifying condition, your pediatrician should be able to help you write an appeal to your insurance company stating that getting Synagis is a medical necessity.
Knowing when to give or get a vaccine doesn’t usually cause any confusion.
You simply have to check the immunization schedule.
Take the meningococcal vaccines, for example. Most parents and pediatricians understand that kids get them before entering middle school and again before going off to college. And some high risk kids should get them even earlier, as infants.
At What Age Should Kids Get a Meningococcal Vaccine?
Actually, there are some things that make it a little more complicated than it should be…
some overnight and summer camps are actually starting to require a dose of meningococcal vaccine for younger kids, even though this is not a formal recommendation of the CDC or AAP
some parents might request a dose of meningococcal vaccine for younger kids going to overnight and summer camps, even though this is not a formal recommendation of the CDC or AAP
some folks are misunderstanding recommendations that campers be up-to-date on all immunizations as a recommendation that they get an early meningococcal vaccine
getting an early dose, before age 10 years won’t count as the middle school dose, and will need to be repeated
some states have very strict laws on timing, like that kids have to get their meningococcal vaccine before starting 6th grade, but only after they turn 11 years old, which creates a problem for those kids who start 6th grade before they are 11 years old
It is not to skip or delay your child’s meningococcal vaccine, of course.
Instead, states should likely institute their meningococcal vaccine laws to require a dose before entering 7th grade, that way, most will have plenty of time to get it while they are in 6th grade. Or at least keep to the standard minimum age of 10 years for a dose to count towards middle school requirements.
What about a meningococcal vaccine for campers?
“In New York State, PHL Article 21, Title 6, Section 2167 also requires the notification of campers and parents about recommendations for and the availability of meningococcal vaccine for all campers attending overnight camps for a period of 7 or more consecutive nights. Meningococcal ACWY (MenACWY) vaccine is recommended at age 11 or 12 years, with a booster dose at age 16 years. Please note that the NYSDOH does not recommend that campers receive either dose of MenACWY vaccine before the recommended ages. Students who are vaccinated before the recommended ages may need to have the doses repeated in order to attend school.”
Recommended Immunizations for Campers
Unless they are in a high risk group, folks should likely stick to the standard ages of the immunization schedule to get their kids vaccinated.
And keep in mind that if your child does get an early dose, it won’t count as part of the routine series and will have to be repeated.
“Doses of quadrivalent meningococcal vaccine (either MPSV4 or MenACWY) given before 10 years of age should not be counted as part of the routine 2-dose series. If a child received a dose of either MPSV4 or MenACWY before age 10 years, they should receive a dose of MenACWY at 11 or 12 years and a booster dose at age 16 years.”
Ask the Experts Meningococcal ACWY
Talk to your pediatrician about an early dose if the extra coverage is important to you though. It will protect your child, but isn’t a general recommendation because younger kids have a lower risk for disease and vaccinating everyone likely wouldn’t impact disease rates that much.
Another situation in which getting an extra dose may be required is if you are traveling to a high risk part of the world. In this case, the extra dose is essential, even if it has to be repeated later.
Wearing a surgical mask is very common when people are sick and want to avoid spreading their germs to others. They are also commonly worn when people are healthy and are just afraid of getting sick.
Why Do Some Folks Wear a Mask During Flu Season?
Is that why you see some folks wearing masks during flu season?
Maybe, but some folks actually have to wear a mask during flu season.
Well, they have to because they decide they don’t want to get a flu vaccine, but still want to keep their job that could put others at risk if they got sick with the flu. So basically, it is unvaccinated health care personal and others who work around sick and vulnerable people who might have to wear a mask when they are at work.
Why don’t they just get vaccinated and protected against the flu?
That’s a good question…
Some other questions to consider as you think about flu vaccine mandates include:
Do unvaccinated health care workers pose a risk to others in the course of their jobs? Of course they do. Health care personal are at high risk to get the flu, since they are often around people who are sick with the flu, and are at higher risk to get the flu if they are unvaccinated.
Does wearing a mask protect anyone? – Yes, they actually do and recent studies have concluded that “surgical face masks worn by infected persons are potentially an effective means of limiting the spread of influenza.”
Does getting a flu shot prevent you from catching the flu? – Flu shots aren’t the most effective vaccine we have, but they are the best way to avoid catching the flu, being 10 to 60% effective since 2004.
Does getting a flu shot prevent you from spreading the flu to others? Yes, and several studies have shown lower rates of nosocomial cases among hospitalized patients as more health care personal get vaccinated!
Does getting a flu shot just cause you to have milder symptoms? The flu vaccine does has many benefits besides preventing the flu, but it is certainly not limited to just causing milder symptoms.
Does wearing a mask violate your HIPAA rights? No. Unless you announce it, no one knows why you are wearing a face mask. Maybe you have herpes or a cold or are just afraid of getting sick. And the Health Insurance Portability and Accountability Act only protects patients, not employees.
So why don’t all health care personal get a flu vaccine each year?
And while some people seem to be against the idea of mandates for health care workers getting flu shots, most think it is a great idea.
“I support this requirement. I think it is a good idea. Ethically, it makes total sense. First, every doctor, nurse, and HCW knows that they are supposed to put patient interests ahead of their own interests. Whatever you think about flu shots, it is good for patients that their healthcare providers are vaccinated against the flu, particularly among patients who cannot themselves be vaccinated, such as some of the elderly, babies, people with immune diseases, and people who just received transplants or are getting cancer treatment. Vaccination does not help them. They are all immunosuppressed.”
Art Caplan on The Law: Get a Flu Shot or Wear a Mask, Healthcare Workers!
In fact, most think that there is both an ethical and a legal rationale for flu vaccine mandates for health care workers.
“Doctors and other healthcare providers have an ethical obligation to make decisions and take actions that protect patients from preventable harm. 5 Many patients are highly vulnerable to flu, so choosing not to be vaccinated is choosing to do harm—a choice that has no place in healthcare.”
Doctors choosing not to be vaccinated is choosing to do harm
It is hard to imagine that some doctors and nurses not only skip getting vaccinated, putting others at risk, but then don’t even want to wear a mask.
It’s easy to be anti-vaccine when you are hiding in the herd. You don’t get vaccinated and you don’t vaccinate your kids, and instead, you simply rely on the fact that everyone else around you is vaccinated to protect you from vaccine-preventable diseases.
Of course, this is a terrible strategy, as we are seeing with the increase in cases of measles and pertussis, etc. It is much better to learn about the importance and safety of vaccines, get fully vaccinated, and stop these outbreaks.
But as they continue to tell you that vaccines don’t work, how about asking what they would do in these ten high-risk situations?
Amazingly, some folks continue to try and justify skipping vaccines and accept the risk of disease, even when that risk is much higher than usual and they could be putting their child’s life in immediate danger!
How will you do with our quiz?
Would you choose to vaccinate in these situations?
1. Baby born to mother with hepatitis B.
You are pregnant and have chronic hepatitis B (positive for both HBsAg and HBeAg). Should your newborn baby get a hepatitis B shot and HBIG?
Many anti-vaccine experts tell parents to skip their baby’s hepatitis B shot, saying it is dangerous, not necessary, or doesn’t work (typical anti-vax myths and misinformation).
However, it is well known that:
from 10 (HBeAg negative) to 90% (HBeAg positive) of infants who are born to a mother with chronic hepatitis B will become infected
90% of infants who get hepatitis B from their mother at birth develop chronic infections
25% of people with chronic hepatitis B infections die from liver failure and liver cancer
use of hepatitis B immune globulin (HBIG) and hepatitis B vaccine series greatly decreases a newborn’s risk of developing a hepatitis B infection (perinatal transmission of hepatitis B), especially if HBIG and the first hepatitis B shot is given within 12 hours of the baby being born
Would your newborn baby get a hepatitis B shot and HBIG?
2. Your child is bitten by a rabid dog.
Your toddler is bitten by a dog that is almost certainly rabid. Several wild animals in the area have been found to be rabid recently and the usual playful and well-mannered dog was acting strangely and died a few hours later. The dog was not vaccinated against rabies and unfortunately, the owners, fearing they would get in trouble, disappeared with the dead dog, so it can’t be quarantined. Should your child get a rabies shot?
Although now uncommon in dogs, rabies still occurs in wild animals, including raccoons, skunks, bats, and foxes. These animals can then expose and infect unvaccinated dogs, cats, and ferrets, etc.
To help prevent rabies, which is not usually treatable, in addition to immediately cleaning the wound, people should get human rabies immune globulin (RIG) and rabies vaccine.
The rabies vaccine is given as a series of four doses on the day of exposure to the animal with suspected rabies and then again on days 3, 7, and 14.
Although rare in the United States, at least 1 to 3 people do still die of rabies each year. The rabies vaccine series and rabies immune globulin are preventative, however, without them, rabies is almost always fatal once you develop symptoms. A few people have survived with a new treatment, the Milwaukee protocol, without getting rabies shots, but many more have failed the treatment and have died.
Although the first MMR vaccine is routinely given when children are 12 months old, it is now recommended that infants get vaccinated as early as age six months if they will be traveling out of the country.
Since the endemic spread of measles was stopped in 2000, almost all cases are now linked to unvaccinated travelers, some of whom start very large outbreaks that are hard to contain.
Would you both get vaccinated before making the trip?
4. Tetanus shot.
Your unvaccinated teen gets a very deep puncture wound while doing yard work. A few hours later, your neighbor comes by to give you an update on his wife who has been in the hospital all week. She has been diagnosed with tetanus. She had gotten sick after going yard work in the same area and has been moved to the ICU. Do you get him a tetanus shot?
Most children get vaccinated against tetanus when they receive the 4 dose primary DTaP series, the DTaP booster at age 4-6 years, and the Tdap booster at age 11-12 years.
Unlike most other vaccine-preventable diseases, tetanus is not contagious. The spores of tetanus bacteria (Clostridium tetani) are instead found in the soil and in the intestines and feces of many animals, including dogs, cats, and horses, etc.
Although the tetanus spores are common in soil, they need low oxygen conditions to germinate. That’s why you aren’t at risk for tetanus every time your hands get dirty. A puncture wound creates the perfect conditions for tetanus though, especially a deep wound, as it will be hard to clean out the tiny tetanus spores, and there won’t be much oxygen at the inner parts of the wound.
These types of deep wounds that are associated with tetanus infections might including stepping on a nail, getting poked by a splinter or thorn, and animal bites, etc. Keep in mind that some of these things, like a cat bite, might put you at risk because you simply had dirt/tetanus spores on your skin, which get pushed deep into the wound when the cat bites you.
Symptoms of tetanus typically develop after about 8 days and might include classic lockjaw, neck stiffness, trouble swallowing, muscle spasms, and difficulty breathing. Even with treatment, tetanus is fatal in about 11% of people and recovery takes months.
Would you get your teen a tetanus shot?
5. Cocooning to protect baby from pertussis.
Both of your unvaccinated teens go to school with a personal belief vaccine exemption. You are due in a few months and are a little concerned about the new baby because there have been outbreaks of pertussis in the community, especially at their highschool. Should everyone in the family get a Tdap shot?
Pertussis, or whooping cough, classically causes a cough that can last for weeks to months.
While often mild in teens and adults, pertussis can be life-threatening in newborns and infants. In fact, it is young children who often develop the classic high-pitched whooping sound as they try to breath after a long coughing fit.
In a recent outbreak of pertussis in California, 10 infants died. Almost all were less than 2 months old.
Since infants aren’t protected until they get at least three doses of a pertussis vaccine, usually at age 6 months, experts recommend a cocooning strategy to protect newborns and young infants from pertussis. With cocooning, all children, teens, and adults who will be around the baby are vaccinated against pertussis (and other vaccine-preventable diseases), so that they can’t catch pertussis and bring it home.
There is even evidence that a pregnancy dose of Tdap can help protect infants even more than waiting until after the baby is born to get a Tdap shot.
Would everyone in your family get a Tdap shot?
6. Nephew is getting chemotherapy.
Your nephew was just diagnosed with leukemia and is going to start chemotherapy. Your kids have never been vaccinated against chicken pox and haven’t had the disease either. Your brother asks that you get them vaccinated, since they are around their cousin very often and he doesn’t want to put him at risk.
Do you get your kids vaccinated with the chicken pox vaccine?
Kids with cancer who are getting chemotherapy become very vulnerable to most vaccine-preventable diseases, whether it is measles, flu, or chicken pox.
According to the Immune Deficiency Foundation, “We want to create a ‘protective cocoon’ of immunized persons surrounding patients with primary immunodeficiency diseases so that they have less chance of being exposed to a potentially serious infection like influenza.”
Would your get your kids vaccinated with the chicken pox vaccine?
7. Outbreak of meningococcemia at your kid’s college.
Background information: Neisseria meningitidis is a bacteria that can cause bacterial meningitis and sepsis (meningococcemia).
Depending on the type, it can occur either in teens and young adults (serogroups B, C, and Y) or infants (serogroup B).
Although not nearly as common as some other vaccine-preventable diseases, like measles or pertussis, it is one of the more deadly. Meningococcemia is fatal in up to 40% of cases and up to 20% of children and teens who survive a meningococcal infection might have hearing loss, loss of one or more limbs, or neurologic damage.
Meningococcal vaccines are available (Menactra and Menveo) and routinely given to older children and teens to help prevent meningococcal infections (serogroups A, C, Y and W-135). Other vaccines, Bexasero and Trumenba, protect against serogroup B and are recommended for high risk kids and anyone else who wants to decrease their risk of getting Men B disease.
Would you encourage her to get vaccinated against meningococcemia?
8. Cochlear implants.
Your preschooler has just received cochlear implants. Should he get the Prevnar and Pneumovax vaccines?
Cochlear implants can put your child at increased risk for bacterial meningitis caused by the Streptococcus pneumoniae bacteria (pneumococcus).
Your child is going to have his spleen removed to prevent complications of hereditary spherocytosis. Should he get the meningococcal and pneumococcal vaccines first?
Without a spleen, kids are at risk for many bacterial infections, including severe infections caused by Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis bacteria.
In addition to their routine vaccines, kids with asplenia might need Menveo or Menactra, Bexsero or Trumenba (Men B), and Pneumovax 23.
Would your child get these vaccines that are recommended for kids with asplenia?
Ebola is returning, but this time an experimental vaccine is available.
There were nearly 30,000 cases and just over 11,000 deaths during the 2014-16 Ebola outbreak in West Africa.
You are in an area that is seeing an increasing number of Ebola cases and there is still no treatment for this deadly disease. An experimental vaccine is being offered.
Do you get the vaccine?
How Anti-Vaccine Are You?
It’s easy to be anti-vaccine when you are hiding in the herd – seemingly protected by all of the vaccinated people around you.
Specifically, there is a risk for severe infections from the Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis bacteria.
Fortunately, there are vaccines that protect against many subtypes of these bacteria, including:
Hib – protects against Haemophilus influenzae type B
Meningococcal conjugate vaccines – Menactra or Menveo, which protect against 4 common types of the Neisseria meningitidis bacteria – serogroups ACWY
Serogroup B Meningococcal vaccines – Bexsero or Trunemba, which protect against Neisseria meningitidis serogroup B
Prevnar 13 – protects against 13 subtypes of Streptococcus pneumoniae
Pneumovax 23 – protects against 23 subtypes of Streptococcus pneumoniae
Although Prevnar, Hib, and the meningococcal vaccines (Menactra or Menveo and Bexsero or Trunemba) are part of the routine immunization schedule, there are additional recommendations that can change the timing for when kids get them if they have asplenia.
According to the latest recommendations, in addition to all of the other routine immunizations that they should get according to schedule, children with asplenia should get:
one dose of the Hib vaccine if they are older than age 5 years “who are asplenic or who are scheduled for an elective splenectomy” and have not already vaccinated against Hib. Unvaccinated younger kids should get caught up as soon as possible. In general though, Hib is given according to the standard immunization schedule. This recommendation is about kids who are behind on the shot.
two doses of a meningococcal conjugate vaccine, either Menactra or Menveo, two months apart once a child with asplenia is at least two years old and a booster dose every five years. Infants with asplenia can instead get a primary series of Menveo at 2, 4, 6, and 12 months, with a first booster dose after three years, and a second booster after another five years. Older infants can get Menactra at 9 and 12 months, again, with a first booster dose after three years, and a second booster after another five years. While these vaccines are recommended for all kids, those with asplenia get them much earlier than the standard age.
either a two dose series of Bexsero or a three dose series of Trunemba, once they are at least 10 years old. The Men B vaccines are only formally recommended for high risk kids, others can get it if they want to be protected.
between one to four doses of Prevnar, depending on how old they are when they start and complete the series. Keep in mind that unlike healthy children who do not routinely get Prevnar after they are 5 years old, older children with asplenia can get a single dose of Prevnar up to age 65 years if they have never had it before. Like Hib, this recommendation is about kids who are behind on the shot.
a dose of Pneumovax 23 once they are at least two years old, with a repeat dose five years later and a maximum of two total doses. Kids who are not high risk typically don’t get this vaccine.
Ideally, children would get these vaccines at least two to three weeks before they were going to get a planned splenectomy. Of course, that isn’t always possible in the case of the emergency removal of a child’s spleen, in which case they should get the vaccines as soon as they can.
More About Asplenia
In addition to these vaccines, preventative antibiotics are typically given once a child’s spleen is removed or is no longer working well. Although there are no definitive guidelines for all children who have had a splenectomy, many experts recommend daily antibiotics (usually penicillin or amoxicillin) until a child is at least 5 years old and for at least 1 year after their splenectomy.
Other less common bacteria that can be a risk for children with asplenia can include Escherichia coli, Staphylococcus aureus, Salmonella species, Klebsiella species, and Pseudomonas aeruginosa. Vaccines aren’t yet available for these bacteria, so you might take other precautions, such as avoiding pet reptiles, which can put kids at risk for Salmonella infections.
Children with asplenia are at increased risk for severe malaria and babesiosis (a tickborne illness) infections. That makes it important to take malaria preventative medications and avoid mosquitoes if traveling to places that have high rates of malaria and to do daily tick checks when camping, etc.
A medical alert type bracelet, indicating that your child has had his spleen removed, can be a good idea in case he ends up in the emergency room with a fever and doctors don’t know his medical history.
Keep in mind that since there are many different causes of asplenia, the specific treatment plan for your child may be a little different than that described here. Talk to your pediatrician and any pediatric specialists that your child sees.
What to Know about Vaccines for Children with Asplenia
Children with asplenia typically need extra vaccines and protection against pneumococcal disease, Hib, and meningococcal disease.